Provider Demographics
NPI:1508022179
Name:KHOJASTEH, SOORENA (MD)
Entity Type:Individual
Prefix:DR
First Name:SOORENA
Middle Name:
Last Name:KHOJASTEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE STE 261
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-658-1928
Mailing Address - Fax:484-572-0482
Practice Address - Street 1:100 E LANCASTER AVE STE 261
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:610-658-1928
Practice Address - Fax:484-572-0482
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD439502207LP2900X
MA254960208VP0014X, 208000000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics